The COVID-19 pandemic has resulted in an incomparable disease burden worldwide. One of the main contributors stems from the multisystem inflammatory syndrome associated with SARS-CoV-2 infection. The numbers of those affected continue to rise with the increasing number of confirmed COVID-19 cases. However, we are yet to fully comprehend the risk factors, disease progression and prognosis for individuals affected. We describe a case of a previously healthy 17-year-old boy who tested positive for the SARS-CoV-2 virus. He presented with a 5-day history of mild influenza-like symptoms, however, quickly required ventilatory support in the intensive care unit. Two months postdischarge, he developed an isolated petechial rash on his palms and soles. His cutaneous presentation was in association with a mixed sensorimotor peripheral neuropathy, debilitating neuropathic pain and intermittent respiratory distress. We postulate that cutaneous manifestations post-COVID-19 could be indicatory of the newly identified multisystem inflammatory syndrome.
WB has no relevant disclosures. JM is an editorial board member of Journal of Dermatology Nurses Association (JDNA) and Journal of Medical Internet Research Dermatology (JMIR Dermatology). JM is an active Cochrane member of the SKIN group. HWL is an investigator for Incyte, L'Oreal, Pfizer and PCORI, has served as consultant for Pierre Fabre, ISDIN, Ferndale, La Roche-Posay, Cantabria and Beiersdorf and has participated as a speaker in general educational sessions for La Roche-Posay and Cantabria Labs.
A 69-year-old woman presented with an 18-month history of recurrent bruising of the eyelids. She was otherwise asymptomatic and systems review was unremarkable. On examination, she had peri-orbital purpura and waxy papules at the inner canthus of both eyes. Macroglossia was also noted. Subcutaneous abdominal biopsy identified amorphous material in the dermis that stained positive for Congo red, with apple-green birefringence seen under polarised microscopy. Immunohistochemistry demonstrated antibodies against lambda light chains. Bone marrow biopsy identified further deposits of immunoglobulin light chain amyloid and a clonal infiltrate with 10%–20% plasma cells, confirming amyloidosis secondary to multiple myeloma. Iodine-123-labelled serum amyloid protein scintigraphy showed no abnormal uptake, thereby excluding significant amyloid deposits in the liver, spleen or kidneys. Cardiac MRI was consistent with early amyloid infiltration. We highlight the importance of dermatological manifestations in amyloidosis, to allow for early diagnosis, potentially limiting end organ involvement.
at a maintenance dosage of 30 mg to 50 mg daily, it is a highly effective treatment. Adverse reactions are dose-related and generally typical of hypervitaminosis A. As acitretin has no immunomodulatory effects in comparison to conventional treatments, it is thus a superior option in conjunction with ongoing treatment with immune checkpoint inhibitors.To date there are no treatment guidelines for this unique patient cohort and often immunotherapy is ceased in the setting of an acute symptomatic cutaneous adverse event. However, in cases of anti-PD-1 induced or exacerbated psoriasis, we recommend a timely dermatological consult with consideration of acitretin alongside ongoing immunotherapy.
which was observed in our patient. Nevertheless, the diagnosis of POEMS syndrome-associated multicentric Castleman disease was not supported by the absence of peripheral neuropathy in our case. 3 Prior to anakinra treatment, we treated the patient with tocilizumab, 4 which only partially improved urticarial rash on the localized erythematous patches. On the other hand, the administration of anakinra demonstrated prompt favourable responses to clinical manifestations. 2 Taken together, although the possibility of Castleman disease and cutaneous plasmacytosis cannot be completely excluded, our case is considered as Schnitzler syndrome.We agree with the insightful notion by Dr Wang that skinassociated lymphoid tissue (SALT) can be formed under the influence of hypercytokinaemia as a sign of systemic disease. Therefore, we termed these lymphoid follicles as inducible SALT (iSALT). It is yet to be elucidated whether iSALT formation is a characteristic of Schnitzler syndrome or a unique phenomenon detected in our patient, who manifested wheals on recurrent localized erythema, which is not commonly observed in Schnitzler syndrome. We believe that further investigation is required to clarify the pathogenesis and the function of iSALT in various skin diseases. Acknowledgments: We thank Dr Prof. H. Kawabata of Kanazawa Medical University for his informative guidance about the diagnosis of Castleman disease.
What is known and objective: Fumaric acid esters (FAEs) have been used for fifty years to treat moderate-to-severe psoriasis. However, recent case reports of progressive multifocal leukoencephalopathy, associated with FAE-induced lymphopaenia, have been a cause for concern (J Dtsch Dermatol Ges. 2009;7:603). Case series:We report six cases of persistent lymphopaenia following cessation of treatment with FAEs, with a mean duration of lymphopaenia of 33 months.
Cutaneous squamous cell carcinoma (cSCC) is a keratinocyte tumour with inherent metastatic potential. Approximately 4% of cSCCs metastasize locoregionally and/or distally. Mohs micrographic surgery (MMS) is efficacious, with cure rates in selected cases of 95–99%. Diagnoses of cSCC treated at St James’s Hospital between the years 2010 and 2019 were identified via histopathology reports. Clinicopathological and treatment data in cases with metastatic disease were collected. Nodal metastasis was defined as biopsy-confirmed cSCC in locoregional lymph nodes and/or supporting radiological evidence. During the timeframe, 3455 cSCCs occurred in 2522 patients. Metastatic disease was identified in 116 patients, with complete data available in 105 cases. Six patients had undergone MMS to the primary tumour. Mean age at time of surgery was 75.6 years (range 65–85); five patients were male. Tumours were located on the cheek (n = 2), ear (n = 2), lower eyelid and nasal tip. Mean time to first metastasis was 6.67 months (range 2–16). Two patients were immunosuppressed at time of metastasis. All patients demonstrated high-risk cSCC features, with four patients demonstrating very-high-risk features as defined by the British Association of Dermatologists. One patient received adjuvant radiotherapy prior to detectable metastasis. All patients were discussed at either skin or head and neck multidisciplinary team (MDT) meetings. No patient received preoperative imaging. This series highlights the importance of risk stratification in cSCC management, irrespective of treatment modality. Consideration should be given to patient age and relative immune status, with dedicated locoregional imaging being guided by MDT discussion.
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